Case, Gretchen A. MA, PhD; Brauner, Daniel J. MD
Teaching students and physicians how to interact with patients in a compassionate and empathetic manner while still attending to the more factual and scientific aspects of this communication is a crucial agenda item for both undergraduate and postgraduate medical curricula. Our intent in writing this article is to present some new possibilities for instructive engagement with empathy. These possibilities arise from the methodology of performance studies, a field of academic study that addresses many theories and practices of performance and crosses disciplines ranging from anthropology to theater. In applying this approach, we raise concerns about current pedagogical approaches to empathy. Performance studies offers a paradigm for teaching doctors to identify and critique the professional roles that they play daily and to choose their words and gestures deliberately so that their interactions with patients become more empathetic, compassionate, and thoughtful. Underlying this approach, we develop the concept of the empathetic imagination as the embodiment of the application of performance theories and practices to the medical encounter.
Empathetic Imagination and Acting
The importance of empathizing with the patient has long been recognized as an essential aspect of physician behavior. A notable entry in the modern medical literature appeared in 1938.1 Current methods aimed at improving empathetic responses by physicians to their patients have been directed at helping physicians to first recognize specific empathic opportunities, prompted by expressions of emotion from the patient, and then develop appropriate responses.2 However, when this model was recently applied to analyze medical encounters between oncologists and patients with advanced cancer—an encounter necessarily fraught with potential emotional content—few empathetic opportunities were presented by patients, and responses to them by physicians with empathetic statements were infrequent.3 There are many potential explanations for this finding, which likely is typical of many doctor–patient communications, but it points clearly to a fundamental problem in the nature of this discourse. How can we improve this situation?
The ability to encourage patients to express their emotional experiences and the ability to respond appropriately stem directly from a thorough understanding of one's own empathetic practices. How empathy is experienced and expressed depends on the unpredictable variables presented in each unique clinical encounter. To participate in any opportunity for communicating empathy, the physician must make full use of his or her empathetic imagination.
As we define it here, empathetic imagination is a cognitive skill set that helps one to imagine the experiences and responses of another person. Empathetic imagination as a concept took hold in the European Age of Enlightenment, although some philosophers trace its roots to earlier centuries. Empathetic imagination allows one to think with the Other by thinking as the Other.4 One practical application of this thinking is that by fully appreciating another—and possibly oppositional—viewpoint, one can attempt to reconcile that viewpoint with one's own. The rational understanding that one can never truly leave one's own point of view behind leads to the compromise of thinking as if one is the Other. Thinking and behaving as if is at the heart of theatrical performance; indeed, philosophers have turned to metaphors of theater to explain practices of empathetic imagination.4,5
Thus, incorporating theory from performance studies helps us conceptualize empathetic imagination as an inventive process for generating ideas, solving problems, and creating possibilities from a perspective that is firmly situated in a wish to understand the patient's embodied experience. For those who participate in medical encounters with patients, a well-developed empathetic imagination is a necessary ability and, most importantly, one that requires guided development.
The notion of bringing imagination to the doctor–patient relationship may strike some as an unscientific intrusion; however, imagination is at work in every therapeutic encounter and is crucial to effective communication with patients.6 For the patient, imagination is necessary for conceptualizing any intervention as potentially helpful.7 When appreciated in its broader sense, imagination is an integral process to the everyday work of any physician trying to understand, empathize, and care for patients. The physician needs to imagine the person in front of him or her as a patient, who is a person seeking help to optimize his or her health. Appreciating the asymmetry between the person who comes to us for help and that individual's prior (or desired) healthier self is an imaginative act. Conceiving of possible future scenarios for the patient—prognostication—is an imaginative act. Of course, this imaginative work should be based on solid historical and observable information. Finally, empathetic imagination requires the physician to use his or her imagination to understand and appreciate the experience and feelings of the patient.
Applying Performance Theory to Clinical Care and Teaching
Multiple performance theories offer support for analyzing interactions in clinical situations by recognizing that every person in the patient's room and hospital corridor is performing his or her role. Arguing that a medical professional is performing a role is not an accusation of fakery but, rather, an acknowledgment of learned behaviors developed to meet critical objectives. These roles include appropriate and symbolic costumes, notably the white coats of the doctors and the loose gowns of the patients. Scripts are followed closely, having been learned—and sometimes consciously rehearsed—before the performance. Before rounds begin, medical students practice giving a patient's history to the supervising physician. Long before that, medical students learn the procedure for asking the patient the appropriate questions to obtain the history. Likewise, patients are following cultural and social scripts regarding the “correct” answers that they hope will get them the best care. Doctors who understand that their own role includes witnessing the performances of the patient and of the other persons involved in the patient's care can create empathy through thoughtful listening and observation.
Rounds are a prime example of a performance that occurs regularly during the training of a physician. New performers learn by watching more seasoned professionals, and they often incorporate the techniques and attitudes of these mentors with or without conscious knowledge of doing so. They can also incorporate explicitly stated feedback into the development of their performance skills by recognizing and processing important teaching moments, such as when the attending physician cautions students who inappropriately discuss a patient while in a public elevator. The importance of role modeling has long been appreciated by medical educators, with more recent analysis warning that role modeling without contextual discussion is not an adequate method of instruction.8
Theories associated with performance studies recognize that acting represents a spectrum of human activity ranging from theatrical productions to religious rituals to workplace encounters.9–12 Performance is not based on concealing or falsifying oneself using scripted discourse but, rather, on revealing one's inner response to the Other. Even theatrical acting, which freely acknowledges the stage, comes from imagining the lives and circumstances of others. Once we acknowledge that performance occurs in everyday spaces, such as hospitals, we can begin to engage in critical discourse about these performances. Performance studies offers a construct for more conscious learning by insisting that the practice of role modeling and other techniques meant to guide a physician's development must be accompanied by analysis of structure, content, and context.
From a performance studies perspective, attention to performance practices in a medical setting demands an awareness of the limits of theatrical acting. Training in any number of acting techniques is only one possible manifestation of a range of performance practices that could be included in medical education. A more expansive understanding of performance could produce physicians who can better recognize and analyze the terms of a given medical encounter. In doing so, they will be better prepared to comprehend and enact their role as doctors in those everyday dramas without minimizing the very real terms under which these performances take place.
The Standardized Patient Encounter: A Crucial Rehearsal
An important aspect of medical education is the use of standardized patient (SP) interactions as a means for teaching and evaluating communication skills. Currently, the SP encounter is probably the most recognizable and productive use of performance in medical education and, therefore, an apt example when discussing possibilities for applying a performance studies paradigm. By approaching the SP encounter as a real moment of medical performance, albeit one in which the stakes are not as high as in other clinical encounters, students can be encouraged to do the hard work of developing their own unique responses. In doing so, their verbal and nonverbal interactions with patients will arise from their empathetic imaginations rather than from a script.
The great value of the SP encounter as a teaching tool is to provide a controlled environment for practicing new and difficult doctoring skills. However, without careful application, this environment can limit—rather than expand—student skill sets. Although the use of SPs is not, in practice, inflexibly standardized, these encounters risk being scripted such that they reinforce particular ideas about proper behavior for both doctor and patient but do not also allow for personal and situational variables.13,14 Likewise, when grading and examination standards for these encounters are not sufficiently flexible, students might intuit that there are narrowly correct ways of interacting with patients.15 This can lead to formulaic and impersonal interactions between patient and physician and the appearance of lack of empathy. Further, the increasing use of the SP encounter as an evaluative tool—including the evaluation of a student's empathy—can create an environment that encourages students to merely learn to mimic displays of empathy rather than understand the empathy that prompts those displays.16,17
If students perceive that a routine set of gestures earns them success in the SP encounter, absent an experience of the emotion or understanding of the meaning behind those gestures, then this process only encourages a disconnect between how the students act and how they feel. This disconnect may be difficult to overcome and is particularly important to avoid in training for a medical encounter, a situation calling for nuanced communication that often risks being replaced by stereotyped, repetitive, and nonempathetic behavior.
Attempts to improve physician empathy by standardizing elements of interactions with patients continue well beyond the SP encounter. One trend addressing empathy in doctor–patient interactions is the development of programs that make use of the “giving bad news” paradigm.3,18 Although we applaud these attempts to improve on the situation, there are problems with this approach. First, these protocols privilege certain types of talk between doctors and patients. Framing certain conversations as “bad news” and encouraging physicians to use particular approaches with these conversations may diminish physicians' attention to other, equally important conversations. Interactions that seem benign may elicit strong reactions in patients; missing these reactions means missing empathetic opportunities. If the purpose of these techniques is to identify empathetic opportunities and develop responses to them, then formulaic responses, which lack the employment of empathetic imagination, may subvert that goal. Acronyms, which work well for memorizing the esoteric facts of medicine, are ill used for improving communication. Additionally, by focusing on emotional content, these techniques may actually give short shrift to the explanation of the facts. Patients facing bad news need both clear explanation of facts and an emotionally responsive physician. Meeting both needs in a given interaction necessitates an empathetic imagination.
Applying Performance Studies to Teaching Clinical Skills
The limited medical literature that addresses acting in the context of doctor–patient interactions supports an outmoded approach to using theatrical techniques in teaching students how to behave as doctors. References to acting and medicine often emphasize the importance of simulating empathetic behavior when these emotions are not available to the physician.19,20 Although some physicians have responded with concern, this idea has persisted.21–23 A recent article on the subject of Method acting and medicine perpetuates a troublesome distinction between “surface acting” (acting unconnected to emotions) and “deep acting” (emotionally honest acting), drawn from a psychological model but erroneously associated with theatrical performance. This same article suggests the use of “surface acting”—alongside “deep acting”—to teach future clinicians how to behave during patient interactions by mimicking outward signs of empathy.24 This use of theatrical acting obscures the fact that performance techniques provide philosophies, theories, and exercises for developing imaginative skills. Method acting and other performance practices should be employed only to develop greater capacity for empathy, as opposed to proficiency in simply generating the appearance of empathetic response. Miming empathy does not suffice; the students' goal should be to experience empathy.
An acting class can indeed offer a template for teaching doctors how to develop their empathic imaginations and behave in a more truly empathetic and compassionate manner. When approached analytically, Method acting and other techniques of theatrical acting can have great value for medical students needing practice at self-reflection. Method acting is a philosophy of acting, descending in a complicated genealogy from Konstantin Stanislavski's theatrical work in Russia at the turn of the 20th century. Stanislavski's acting and directing work was revolutionary because he resisted the contemporary popular acting traditions that were concerned with outward presentation and exaggerated gestures. He wanted his acting students to learn by connecting to each character in an individual, meaningful way. The school of acting that emerged from Stanislavski's ideas is opposed to the idea of faking an emotion that is not felt by the actor. Rather, the actor uses his or her own life experiences to help develop the character's emotional responses. Those responses are not learned by rote but are, instead, inextricably and uniquely tied to the “given circumstances.”25–27 The Method, in its many manifestations, encourages the actor to use the “magic if” to consider how he or she would feel if the character's circumstances were his or her own—in short, to empathize.26 This principle could be applied to medical students developing their empathetic imaginations in the context of the SP interaction by providing students and instructors another option for a creative environment and a shared vocabulary.
Despite its accessibility and popularity, Method acting is far from being the only performance technique that can be adopted for cultivating an empathetic imagination as part of a medical education. For example, Augusto Boal's28,29 Theatre of the Oppressed emphasizes the multiple endings possible in any given situation. In one format, performers enact scenes from real life that have unhappy endings. Audience participants give suggestions to redirect the scenes, which are replayed until reaching a better outcome. First conceived for use by politically oppressed communities, Boalean performance practices might be used to help students understand and explore the potential for positive changes in health behavior both in individuals and on a social level.
Another approach might take the form of workshops in the theatrical tradition of Commedia dell'arte, which uses the differences in social status between an established cast of stock characters (including Il Dottore—The Doctor!—who is a pedant and mountebank) to create comedic situations.30,31 Properly contextualized, such humorous Commedia workshops could have serious impact by asking students to consider the status of the doctor in society and the importance of status relationships in the clinical encounter. Such a workshop, by including basic theatrical terms and principles, could also provide physical training useful in the clinical encounter. Deliberate movement, mindful use of space, voice modulation and projection, and appropriate eye contact are necessary not only for effective theatrical performance but also for successful clinical communication.
Already, elective classes focused on Method acting, staged theatrical readings, improvisation, and storytelling have found productive places in medical school curricula.32–34 However, any and all of these approaches should be conceived more generally as part of the rehearsal-and-performance process of medical students becoming doctors. To emphasize one style of acting over any other mode of performance—or to suggest that there is only one way of showing empathy—limits actors and doctors to a practice of regurgitating learned responses rather than developing their own ways of being empathetic.
The performance studies paradigm calls for an understanding of the many ways in which all humans perform their roles, not only in traditional theatrical spaces but also in their homes, communities, and workplaces. By embracing this wider understanding of performance, medical curricula can build on techniques already in place for improving communication and building empathy. Acting techniques and performance exercises such as those described above acquire greater meaning in the context of performance as an everyday occurrence and not just a theatrical event. Armed with the awareness of their own performed roles—and the accompanying objectives—in a clinical encounter, students can more effectively transfer the imaginative work they have done in the SP encounter to the clinical encounter. Under this paradigm, the SP encounter is not an artificial engagement; it is a controlled rehearsal for a live performance, the clinical encounter, in which the possibilities for empathetic discourse are greatly expanded. Under this paradigm, protocols designed, for example, to improve the process of “giving bad news” are indeed scripts, but scripts that are placed intentionally in the hands of individuals who have powers of interpretation and empathetic imaginations.
In striving for the development of an empathetic imagination as part of a medical school curriculum, some important points should be considered. First, imagination necessitates individuation; even in standardized encounters, expressions of empathy should not be standardized. Second, students should not be satisfied with using performance techniques to learn how to mimic others, because their work as physicians will require that their daily behavior be made from a truthful perspective. That perspective will be particular to the individual and the situation and should not be forced into a generic mode.
The empathetic imagination is an important resource for a physician to use in knowing the patient and in considering the possibilities for the patient's past, present, and future states of health. We call for a richer model of communication that explicitly encourages doctors to imagine and relate to the circumstances of others and that offers opportunities to develop these skills.
Developing empathetic imagination will help doctors act appropriately in a broad array of situations. Patients are not standardized, nor are their doctors, and when patients and doctors interact, an enormous number of possible situations can arise. Curricular resources, including the teaching of a wide range of performance techniques and theories, should go toward training doctors who think and act using their unique empathetic imaginations. Theories and practices from performance studies can aid in building a solid framework for the development of this curriculum.
The authors thank the readers of various versions of this essay for their comments: Kathryn Montgomery (Northwestern University), Mark Olson (Duke University), Terri Kapsalis (Art Institute of Chicago), Jeffrey Meanza (Playmakers Repertory Theatre/UNC–Chapel Hill), and members of the Chicago Narrative and Medicine Group.
Other disclosures: None.
Ethical approval: Not applicable.
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